To degree or not to degree: that is NOT the question for UK nursing

Current UK nurse training should focus on a national curriculum, its content and assessment, and not its categorisation as a degree, says Ann Bradshaw

June 24, 2018

In December 1996, before she became the “Domestic Goddess”, Nigella Lawson wrote in the Times that: “Irrelevant academic qualifications are an insult to nurses - and useless to their patients”.  As the Nursing and Midwifery Council publishes new standards for UK nurse education, it is timely to revisit this argument about whether the UK has an adequate nurse preparation programme. 

The Royal College of Nursing Willis Commission, as well as nursing academics such as Hugh McKenna, David Thompson, Roger Watson and Ian Norman in “The good old days of nurse training: rose-tinted or jaundiced view?”, contend that only degrees can prepare nurses. Indeed, they cite a paper by Linda Aiken et al. that nurses with degrees reduce death rates. And they dismiss disagreement as rose-tinted imaginings of a non-existent golden age: only a degree education can make the nurse “analytical, assertive, creative, competent, confident, computer literate, decisive, reflective, embracers of change and the critical doers and consumers of research”. 

While it is not good history to compare nurse preparation in the past with the present because knowledge, skills and requirements inevitably change, it is possible to compare the philosophy behind nurse preparation past and present and raise questions that are still relevant today.  As I have shown elsewhere, from the days of Nightingale, preparing the nurse with a high level of scientific and medical knowledge as well as practical skills was as important as inducting the nurse into the praxis of care and compassion.  This philosophy resulted in 1923 in a national state syllabus and national practical and theoretical examination.

But the national training was lost when nursing leaders persuaded the reluctant Thatcher government to move nurse education into higher education. They were motivated by a desire to increase the status of the profession – not to improve patient care. This was calculated by the National Audit Office in 1992 as £580 million for extra staff to do work previously done by students (now supernumerary) and £207 million to support colleges introducing the new system. One argument used was to improve recruitment, although this was not actually a problem then. It is now.

Since then, there has been the practice of extending the nursing role into medical and even surgical practice. But, as Geoffrey Rivett points out, UK nurse practitioners are not prepared with skills of diagnosis, examination and treatment, like their US counterparts; instead, nurse practitioner courses are philosophical.

So how are nurses now prepared for their own role as well as their expanded role into medical and surgical practice? How does the degree fit them for this? The current Nursing and Midwifery Council standards introduced in 2010 are generic. Each university implements them in its own way with a variety of assessment methods. The Chief Nurse, giving evidence to the Health Committee in 2013 in the wake of the Francis Report did not know, for example, if or where continence care was taught. 

Perhaps it is because of this that the new NMC standards introduced this year list topics to be covered, but these do not include specific diseases, and no details of levels of content, or teaching and assessment methods are given. These standards remain generic. They still lack prescriptive detail despite the Francis Report recommending a national standard of nurse training: “Therefore, nursing training should be reviewed to ensure that sufficient practical elements are incorporated to ensure that a consistent standard is achieved by all trainees throughout the country. This requires national standards.” However, his recommendation seems to have been lost in the reports that followed. Don Berwick, for example, attributed failures of nursing to short staffing, not to variable standards of preparation.   

Skills of analysis, assertiveness, creativity and so on, delineated by McKenna et al. do not explain what the nurse knows and does. In fact any other degrees could and do espouse similar skills and qualities. And no degree, as I have argued elsewhere, can inculcate the art of nursing – kindness, care and compassion – that Francis found missing in nurses at Mid Staffordshire and which in 2012 the Chief Nurses listed as requirements.  Neither does a nursing degree prepare nurses for an extended medical role, as training is not shared with trainee doctors.

Moreover, as Chris Rust pointed out in Times Higher Education, without shared assessment it is impossible to compare UK degree standards. This clearly relates to the nursing degree, and it calls into question The Lancet study published by Aiken. For in stating that graduate nurses reduce mortality, Aiken et al. do not discuss the comparability and quality of the degrees that these nurses have attained.

Nursing degrees differ not only in the UK but in other countries. North American and many European nursing courses are much more medically focused than those in the UK. So what does the degree contain and how is this measured? How is the knowledge and skill of the graduate nurse tested to ensure, as Francis recommends, a consistent standard is achieved? And, interestingly, how does a modern nursing “degree” differ in the level of knowledge and attainment of nurses prepared under the previous system?  Was my own rigorous training at the Radcliffe Infirmary in 1971 a “degree” in reality if not in name?

So the question is not whether nurses should or should not be prepared with a degree, rather it is the deeper question: What is a nursing degree?

 Ann Bradshaw is a senior lecturer in adult nursing at Oxford Brookes University 

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Reader's comments (15)

This article is rightly getting a lot of attention on twitter. The points made by the author are ill-founded and ignore evidence and pedagogy. There is a general lack of logic in this piece, as well as internal contradiction.
The article's argument is clear, that to label a course of training 'a degree' is not the point, it is the content of the course whatever its label. The article skewers the oft cited Aitken review across the USA, Europe and UK that degree nurses save lives: but since they are so massively variable with no common standard at all, this claim is clearly without basis. And within the UK the nursing degrees vary massively, with only very general aspirational hopes from the NMC, no strict syllabuses. UK courses do lack hard biological science as against the US and Europe. Read the Guardian latest on nurses' testimony. The nurse in 2010s https://www.theguardian.com/society/2018/jun/30/life-as-an-nhs-nurse-in-the-10s says " I work with nurses from Italy, Spain and Portugal – over there, nurses are trained to the equivalent of UK junior doctor level. I learn so much from them, but so many of them want to leave because it’s such a hostile environment. Quite often I get patients going: “Oh, I’m glad you’re an English one.” I tell them people who come here to work are trained better. " As the article argues 'degree or not degree, that is not the question', it is the content that matters. Also this nurse says she is in poverty: when trainee nurses were paid members of staff trained on wards, with blocks top quality clinical courses by specialists, they were in employment, the NHS had a full supply of nurses, and arguably care was far better [ see Francis ]. The Willis Report was a pre emptive strike by the Nurses Union written by Jane Salvage as a kind of MPhil not a forensic gathering of evidence like Francis, so is no evidence for 'degree' labelling. The Guardian nurse also testifies to the NHS plundering other nations for nurses, with indigenous recruitment in free.
I have been a Registered Nurse for the past 26 years and quite frankly the amount of educated idiots coming into this job frankly out weighs any benefits that a so called degree might bring, most academics that I have heard being interviewed regard a nursing degree as not worth the paper it's written on. For the record I started out as an SEN.
Bulleid462 "the amount of educated idiots coming into this job frankly out weighs any benefits" That's a worry. In my own experience, the degree nursing students coming through, and I see many, are extremely dedicated, intelligent and compassionate. I can't think of a single one since nursing became degree entry, that I have not been immensely proud of and who hasn't given me hope for the future of nursing. Unfortunately there is a cohort of nurses who are nearing retirement who perpetuate the paternal, hierarchical view that nurses are doctors' handmaidens who should not be educated. Sound familiar Bulleid462?
No it doesn't sound familiar at all, funny that. As that Art Historian the late Brian Sewell wrily observed, One doesn't need a degree in philosophy to be a gardner when he was asked to comment on whether nurses need to have degrees to nurse, a bit of commonsense really which is what nursing is, hardly rocket science is it?
A nursing qualification is NOT a degree; to proffer that it is simply fails to understand both the Education/Training dichotomy and the purpose of a degree. Ann Bradshaw also totally ignores the point of whether it's appropriate to attempt training in an educational establishment. Until she, or indeed anybody, confronts such things all of this 'discussion' is simply unnecessary.
Well...I agree nurses should have degrees and also continuous assessment and mentorship...I think this happens .Unfortunately the dedication and empathy required can be sadly lacking...an article by an 86 year old lady summed it up....you must forget about yourself! In this day and age the outside pressure is huge...also I do think even a bucket load if commonsense will not make you a Nurse Practitioner, prescriber,clinically competent!!!!
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As one of the people named in the opening section I read this with great interest. I completely agree - and myself and the others named - have long called for a return to a national curriculum for nurses - and a common exit exam at the end as the only way to ensure and compare standards - we are in print on this issue. Otherwise I am not entirely sure what point Ann is making here - does she expect the NMC to state every single thing a nurse should know and, presumably, experience? I hardly think that’s possible. But she’s sure opened the floodgates again to the anti education brigade as evidenced by some of the highly unprofessional comments above. I think the great mistake is the expectation that a nurse should come out of a course and be ready to hit the ground running across the enormous range of specialist areas. It’s frankly impossible these days - they need the skills to be able to learn quickly when they move to new areas. And finally, nurses moving into diagnostic and prescribing roles do not learn that philosophically; they have to achieve (I think) 90% in the nurse prescribing exam and spend months of consultant supervised practice before diagnostic skills are assumed safe. The bigger problem here is that the NMC refuses to engage with registering this level of practice.
It's not helpful to label contributors to this debate in pejorative terms; 'anti education' I'm not, 'highly unprofessional' I'm not ... just accept that there are souls in higher education who don't share your beliefs and they are entitled to say so. Additionally, I simply fail to understand why it's unreasonable to expect a graduate nurse to hit the ground running after a University has, de facto, provided him/her with a licence to practise, by awarding him/her with one of their degrees. If the University hasn't provided her/him with such a licence then the process of educating/training that student is flawed and must be questioned. In it's entirety the training of a nurse should be about what they can do in the work place after they have graduated. If the Nurse is not ready to deal with any part of the complexity of the Nursing profession, then the University has failed him/her. At the very least, any training establishment should at least enable the trainee to provide a prima facie case, to would be employers, for further training and further testing; as in other noble professions.
Highly unprofessional am I, really. Coming from a so called academic with a mit mop degree I will take that as a compliment. 26 years as a Nurse with both second level and first level qualifications, yeh right whatever....
Since the requirement for a degree has prevented so many young people from becoming nurses, the NHS has embarked on a barbaric campaign to steal cheap trained nurses from poor countries. WHERE THEY ARE DESPERATELY NEEDED. Meanwhile, poor British people are denied a job and go on the dole. The whole programme is utterly indefensible.
I think Ann's made a very good argument for creation of a national curriculum if not then at least a consideration of comparability in assessment standards. She is right in aiming her criticism at the 1980-90's push for 'status' which drove the wholesale privatisation of NHS schools of nursing. Now each university provider assesses differently and there's little comparability over the product. This may have worked in fields like medicine because there's a clinical academic career route, but that failed to materialise for nursing when the universities incorporated the nursing schools. This is what happens when you sell off a national asset with no effective control: the 'brand' eventually suffers. The 'British SRN' as a gold standard eventually became sullied and no longer garnered any global cachet because it's become meaningless. Fancy the chief nurse not knowing about the nursing curriculum? That speaks volumes about where the profession is today which is bringing back two tier registration because it's seen as a cheaper alternative not because it'll be effective. These are important points that Ann raises which many would wish to ridicule and trivialize but which won't easily go away.
It's unfortunate to read about a Professional Qualification being referred to as a 'Product' and a 'Brand'. Using such references reveals how Universities have contaminated those qualifications which were, until very recently, well understood and which were rightly adorned those who were trusted practitioners in the field.
It would also be good to note the wider context of discussion of universities and degrees, see eg the Reform research document recently produced, including the relationship to professional bodies such as the GMC, Law Society etc. Also Ann's article refers to the issue raised by Chris Rust in Times Higher Education, that without shared assessment it is impossible to compare UK degree standards. This clearly relates to the nursing degree, and it calls into question The Lancet study published by Aiken et al, which fails to discuss the comparability and quality of the degrees that these nurses have attained. There is now a very real fall in good quality recruitment, so the very expensive system is alienating women from a crucial profession.

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